Provider Demographics
NPI:1417543240
Name:EVANGELISTA, FRANK
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SHUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1900
Mailing Address - Country:US
Mailing Address - Phone:860-679-3980
Mailing Address - Fax:860-679-1257
Practice Address - Street 1:11 SHUTTLE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1900
Practice Address - Country:US
Practice Address - Phone:860-679-3980
Practice Address - Fax:860-679-1257
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT42830207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology